Provider Demographics
NPI:1841610672
Name:CROCKETT, BENJAMIN JOEL
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOEL
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11184 SW BEL AIRE LN
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-5918
Mailing Address - Country:US
Mailing Address - Phone:971-322-9186
Mailing Address - Fax:
Practice Address - Street 1:11184 SW BEL AIRE LN
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-5918
Practice Address - Country:US
Practice Address - Phone:971-322-9186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-19
Last Update Date:2014-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker